INTRAVENOUS THERAPY

Nursing Science VI

I. Intravenous Therapy  The butterfly infusion set is used commonly in children and older
 Purpose and uses clients, whose veins are likely to be small or fragile.
o Used to sustain clients who are unable to take substances orally o Plastic cannulas
o Replaces water, electrolytes, and nutrients more rapidly than oral  Plastic cannulas may be an over-the-needle device or an in-needle
administration catheter and are used primarily for short-term therapy.
o Provides immediate access to the vascular system for the rapid  The over-the-needle device is preferred for rapid infusion and is
delivery of specific solutions without the time required for more comfortable for the client.
gastrointestinal tract absorption  The in-needle catheter can cause catheter embolism if the tip of
o Provides a vascular route for the administration of medication or the cannula breaks.
blood components  IV gauges
 Types of solutions o The gauge refers to the diameter of the lumen of the needle or
o Isotonic solutions cannula.
 Have the same osmolality as body fluids o The smaller the gauge number, the larger the diameter of the lumen;
 Increase extracellular fluid volume the larger the gauge number, the smaller the diameter of the lumen.
 Do not enter the cells because no osmotic force exists to shift the o The size of the gauge used depends on the solution to be administered
fluids and the diameter of the available vein.
o Hypotonic solutions o Large-diameter lumens (smaller gauge numbers) allow a higher fluid
 Are more dilute solutions and have a lower osmolality than body rate than smaller diameter lumens and allow the administration of
fluids higher concentrations of solutions.
 Cause the movement of water into cells by osmosis o For rapid emergency fluid administration, blood products, or
 Should be administered slowly to prevent cellular edema anesthetics, large-diameter lumen needles or cannulas are used, such
o Hypertonic solutions as a 14-, 16, 18-, or 19-gauge.
 Are more concentrated solutions and have a higher osmolality o For peripheral fat emulsion (lipids) infusions a 20- or 21-gauge lumen
than body fluids or cannula is used.
 Cause movement of water from cells into the extracellular fluid by o For standard IV fluid and clear liquid IV medications, a 22- or 24-gauge
osmosis lumen or cannula is used.
o Colloids o If the client has very small veins, a 24- to 25-gauge lumen or cannula is
 Also called plasma expanders used.
 Pull fluid from the interstitial compartment into the vascular  IV containers
compartment o Container may be glass or plastic.
 Used to increase the vascular volume rapidly, such as in o Squeeze the plastic bag to ensure intactness and assess the glass
hemorrhage or severe hypovolemia bottle for any cracks before hanging.
II. Intravenous Devices  IV tubing
 IV cannulas o IV tubing contains a spike end for the bag or bottle, drip chamber,
o Butterfly sets roller clamp, Y site, and adapter end for attachment to the cannula or
 The set is a wing-tip needle with a metal cannula, plastic or rubber needle that is inserted into the client’s vein.
wings, and a plastic catheter or hub. o Shorter, secondary tubing is used for piggyback solutions, connecting
 The needle is 0.5 to 1.5 inches in length, with needle gauge sizes them to the injection sites nearest to the drip chamber
from 16 to 26. o Special tubing is used for medication that absorbs into plastic (check
specific medication administration guidelines when administering IV
 Infiltration is more common with these devices.
medications).
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Nursing Science VI
o Vented and nonvented tubing are available.
 A vent allows air to enter the IV container as the fluid leaves.
 A vented adapter can be used to add a vent to a nonvented IV
tubing system.
 Use nonvented tubing for flexible containers.
 Use vented tubing for glass or rigid plastic containers to allow air
to enter and displace the fluid as it leaves; fluid will not flow from
a rigid IV container unless it is vented.
 Drip chambers
o Macrodrip chamber
 The chamber is used if the solution is thick or is to be infused
rapidly.
 The drop factor varies from 10 to 20 drops (gtt)/mL, depending on
the manufacturer.
 Read the tubing package to determine how many drops per
milliliter are delivered (drop factor).
 Microdrip chamber
o Normally, the chamber has a short vertical metal piece (stylet) where
the drop forms.
o The chamber delivers about 60 gtt/mL.
o Read the tubing package to determine the drop factor (gtt/mL).
o Microdrip chambers are used if fluid will be infused at a slow rate (less
than 50 mL/hour) or if the solution contains potent medication that
needs to be titrated, such as in a critical care setting or in pediatric
clients.
 Filters
o Filters provide protection by preventing particles from entering the
client’s veins.
o They are used in IV lines to trap small particles such as undissolved
substances, or medications that have precipitated in solution.
o Assess the agency policy regarding the use of filters.
o A 0.22-μm filter is used for most solutions; a 1.2-μm filter is used for
solutions containing lipids or albumin; and a special filter is used for
blood components.
o Change filters every 24 to 72 hours (depending on agency policy) to
prevent bacterial growth.
 Needleless infusion devices
o Needleless infusion devices include recessed needles, plastic cannulas,
and one-way valves; these systems decrease the exposure to
contaminated needles.
o Do not administer parenteral nutrition or blood products through a
one-way valve.
 Intermittent infusion devices
o Intermittent infusion devices are used when intravascular accessibility
is desired for intermittent administration of medications by IV push or
IV piggyback.”
o Patency is maintained by periodic flushing with normal saline solution
(sodium chloride and normal saline are interchangeable names).
o Depending on agency policy, when administering medication, flush
with 1 to 2 mL of normal saline to confirm placement of the IV
cannula; administer the prescribed medication and then flush the
cannula again with 1 to 2 mL of normal saline to maintain patency.
 Electronic IV infusion devices
o IV infusion pumps control the amount of fluid infusing and should be
used with central venous lines, arterial lines, solutions containing
medication, and parenteral nutrition infusions. Most agencies use IV
pumps for the infusion of any IV solution.
o A syringe pump is used when a small volume of medication is
administered; the syringe that contains the medication and solution
fits into a pump and is set to deliver the medication at a controlled
rate.
o Patient-controlled analgesia (PCA) is a device that allows the client to
self-administer IV medication, such as an analgesic; the client can
administer bolus doses at set intervals and the pump can be set to lock
out bolus doses that are not within the preset time frame to prevent
overdose. The PCA regimen may include a basal rate of infusion along
with the demand dosing.
III. Latex Allergy
 Assess the client for an allergy to latex.
 IV supplies, including IV catheters, IV tubing, IV ports (particularly IV rubber
injection ports), rubber stoppers on multidose vials, and adhesive tape,
may contain latex.”
 Latex-safe IV supplies need to be used for clients with a latex allergy.
 A three-way stopcock, rather than a rubber injection port, needs to be
used on plastic tubing.
IV. Selection of a Peripheral IV Site
 Veins in the hand, forearm, and antecubital fossa are suitable sites
 Veins in the lower extremities (legs and feet) are not suitable for an adult
client because of the risk of thrombus formation and the possible pooling
of medication in areas of decreased venous return
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Nursing Science VI
 Veins in the scalp and feet may be suitable sites for infants
 Assess the veins of both arms closely before selecting a site.
 Start the IV infusion distally to provide the option of proceeding up the
extremity if the vein is ruptured or infiltration occurs; if infiltration occurs
from the antecubital vein, the lower veins in the same arm usually cannot
be used for further puncture sites.
 Determine the client’s dominant side, and select the opposite side for a
venipuncture site.
 Bending the elbow on the arm with an IV may easily obstruct the flow of
solution, causing infiltration that could lead to thrombophlebitis.
 Avoid checking the blood pressure on the arm receiving the IV infusion if
possible.
 Do not place restraints over the venipuncture site.
 Use an armboard as needed when the venipuncture site is located in an
area of flexion.
V. Addition of Medication to an IV Solution
 Assess for compatibility of medication and solution.
 When adding medication to the IV bag, mix the bag end over end several
times before hanging it to disperse the medication.
 Manufacturer-prepared IV medication systems are available; these
systems are similar to a secondary IV with medication or a piggyback
system.
 Ensure that the medication can be mixed in soft plastic because some
medications absorb into the soft plastic and should be mixed only in glass.
VI. Initiation and Administration of IV Solutions
 Check the IV solution against the health care provider’s (HCP’s)
prescription for the type, amount, percentage of solution, and rate of flow;
follow the six rights for medication administration.
 Assess the health status and medical disorders of the client and identify
client conditions that contraindicate use of a particular IV solution or IV
equipment such as an allergy to cleansing solution, adhesive materials, or
latex.
 Check client’s identification and explain the procedure to the client; assess
client’s previous experience with IV therapy and preference for insertion
site.
 Wash hands thoroughly before inserting an IV line and before working with
an IV line; wear gloves.
 Use sterile technique when inserting an IV line and when changing the
dressing over the IV site.
 Change the venipuncture site every 72 to 96 hours in accordance with
Centers for Disease Control and Prevention (CDC) recommendations and
agency policy.
 Change the IV dressing when the dressing is wet or contaminated, or as
specified by the agency policy.
 Change the IV tubing every 96 hours in a contaminated, or as specified by
the agency policy.
 Change the IV tubing every 96 hours in accordance with CDC
recommendations and agency policy or with change of venipuncture site.
 Do not let an IV bag or bottle of solution hang for more than 24 hours to
diminish the potential for bacterial contamination and possibly sepsis.
 Do not allow the IV tubing to touch the floor to prevent potential bacterial
contamination.
 Before adding medications to solutions, swab access ports with 70%
alcohol, an equally effective solution, or as specified by the agency policy.
 See Priority Nursing Actions for instructions on inserting an IV.
VII. Precautions for IV Lines
 On insertion, an IV line can cause initial pain and discomfort for the client.
 An IV puncture provides a route of entry for microorganisms into the body.
 Medications administered by the IV route enter the blood immediately,
and any adverse reactions or allergic responses can occur immediately.
 Fluid (circulatory) overload or electrolyte imbalances can occur from
excessive or too rapid infusion of IV fluids.
 Incompatibilities between certain solutions and medications can occur.
VIII. Complications
 Air embolism
o Description: A bolus of air enters the vein through an inadequately
primed IV line, from a loose connection, during tubing change, or
during removal of the IV.
o Prevention and interventions
 Prime tubing with fluid before use, and monitor for any air
bubbles in the tubing.
 Secure all connections.
 Replace the IV fluid before the bag or bottle is empty.
 Monitor for signs of air embolism; if suspected, clamp the tubing,
turn the client on the left side with the head of the bed lowered
(Trendelenburg’s position) to trap the air in the right atrium, and
notify the HCP.
 Catheter embolism
o Description: An obstruction that results from breakage of the catheter
tip during IV line insertion or removal
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o Prevention and interventions
 Remove the catheter carefully.
 Inspect the catheter when removed.
 If the catheter tip has broken off, place a tourniquet as proximally
as possible to the IV site on the affected limb, notify the HCP
immediately, prepare to obtain a radiograph, and prepare the
client for surgery to remove the catheter piece(s) if necessary.
 Circulatory overload
o Description: Also known as fluid overload; results from the
administration of fluids too rapidly, especially in a client at risk for
fluid overload
o Prevention and interventions
 Identify clients at risk for circulatory overload.
 Calculate and monitor the drip (flow) rate frequently.
 Use an electronic IV infusion device and frequently check the drip
rate or setting (at least every hour for an adult).
 Add a time tape (label) to the IV bag or bottle next to the volume
markings. Mark on the tape the expected hourly decrease in
volume based upon the mL/hour calculation
 Monitor for signs of circulatory overload. If circulatory overload
occurs, decrease the flow rate to a minimum, at a keep-vein-open
rate; elevate the head of the bed; keep the client warm; assess
lung sounds; assess for edema; and notify the HCP.
 Electrolyte overload
o Description: An electrolyte imbalance is caused by too rapid or
excessive infusion or by use of an inappropriate IV solution
o Prevention and interventions
 Assess laboratory value reports.
 Verify the correct solution.
 Calculate and monitor the flow rate.
 Use an electronic IV infusion device and frequently check the drip
rate or setting (at least every hour for an adult).
 Add a time tape (label) to the IV bag or bottle (see Fig. 14-5).
 Place a red medication sticker on the bag or bottle if a
medication, such as potassium chloride, has been added to the IV
solution (see Fig. 14-5).
 Monitor for signs of an electrolyte imbalance, and notify the HCP
if they occur.
 Hematoma
o Description: The collection of blood in the tissues after an unsuccessful
venipuncture or after the venipuncture site is discontinued and blood
continues to ooze into the tissue
o Prevention and interventions
 When starting an IV, avoid piercing the posterior wall of the vein.
 Do not apply a tourniquet to the extremity immediately after an
unsuccessful venipuncture.
 When discontinuing an IV, apply pressure to the site for 2 to 3
minutes and elevate the extremity; apply pressure longer for
clients with a bleeding disorder or who are taking anticoagulants.
 If a hematoma develops, elevate the extremity and apply pressure
and ice as prescribed.
 Infection
o Description
 Infection occurs from the entry of microorganisms into the body
through the venipuncture site.
 Venipuncture interrupts the integrity of the skin, the first line of
defense against infection.
 The longer the therapy continues, the greater the risk for
infection.
 Infection can occur locally at the IV insertion site or systemically
from the entry of microorganisms into the body.
o At-risk clients
 Immunocompromised clients with diseases such as cancer, human
immunodeficiency virus, or acquired immunodeficiency syndrome
are at risk for infection.
 Clients receiving treatments such as chemotherapy who have an
altered or lowered white blood cell count are at risk for infection.
 Older clients, because aging alters the effectiveness of the
immune system, are at risk for infection.
 Clients with diabetes mellitus are at risk for infection.
o Prevention and interventions
 Assess the client for predisposition to or risk for infection.
 Maintain strict asepsis when caring for the IV site.
 Monitor for signs of local or systemic infection.
 Monitor white blood cell counts.
 Check fluid containers for cracks, leaks, cloudiness, or other
evidence of contamination.
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 Change IV tubing no more frequently than every 96 hours and
agency policy; change IV site dressing when soiled or
contaminated and according to agency policy.
 Label the IV site, bag or bottle, and tubing with the date and time
to ensure that these are changed on time according to agency
policy.
 Ensure that the IV solution is not hanging for more than 24 hours.
 If infection occurs, the HCP is notified; discontinue the IV, and
place the venipuncture device in a sterile container for possible
culture.
 Prepare to obtain blood cultures as prescribed if infection occurs.
 Restart an IV in the opposite arm to differentiate sepsis (systemic
infection) from local infection at the IV site.
 Infiltration
o Description
 Infiltration is seepage of the IV fluid out of the vein and into the
surrounding interstitial spaces.
 Infiltration occurs when an access device has become dislodged or
perforates the wall of the vein or when venous backpressure
occurs because of a clot or venospasm.
o Prevention and interventions
 Avoid venipuncture over an area of flexion.
 Anchor the cannula and a loop of tubing securely with tape.
 Use an armboard or splint as needed if the client is restless or
active.
 Monitor the IV rate for a decrease or a cessation of flow.
 Evaluate the IV site for infiltration by occluding the vein proximal
to the IV site. If the IV fluid continues to flow, the cannula is
probably outside the vein (infiltrated); if the IV flow stops after
occlusion of the vein, the IV device is still in the vein.
 Lower the IV fluid container below the IV site, and monitor for the
appearance of blood in the IV tubing; if blood appears, the IV
device is most likely in the vein.
 If infiltration has occurred, remove the IV device immediately;
elevate the extremity and apply compresses (warm or cool,
depending on the IV solution that was infusing and the HCP’s
prescription) over the affected area.
 Do not rub an infiltrated area, which can cause hematoma.
 Phlebitis and thrombophlebitis
o Description
 Phlebitis is an inflammation of the vein that can occur from
mechanical or chemical (medication) trauma or from a local
infection.
 Phlebitis can cause the development of a clot (thrombophlebitis).
o Prevention and interventions
 Use an IV cannula smaller than the vein, and avoid using very
small veins when administering irritating solutions.
 Avoid using the lower extremities (legs and feet) as an access area
for the IV.
 Avoid venipuncture over an area of flexion.
 Anchor the cannula and a loop of tubing securely with tape.
 Use an armboard or splint as needed if the client is restless or
active.
 Change the venipuncture site every 72 to 96 hours in accordance
with CDC recommendations and agency policy.
 If phlebitis occurs, remove the IV device immediately and restart
it in the opposite extremity; notify the HCP if phlebitis is
suspected, and apply warm, moist compresses, as prescribed.
 If thrombophlebitis occurs, do not irrigate the IV catheter; remove
the IV, notify the HCP, and restart the IV in the opposite
extremity.
 Tissue damage
o Description
 Tissues most commonly damaged include the skin, veins, and
subcutaneous tissue.
 Tissue damage can be uncomfortable and can cause permanent
negative effects.
 Extravasation is a form of tissue damage caused by the seepage of
vesicant or irritant solutions into the tissues; this occurrence
requires immediate health care provider notification so that
treatment can be prescribed to prevent tissue necrosis.
o Prevention and interventions
 Use a careful and gentle approach when applying a tourniquet.
 Avoid tapping the skin over the vein when starting an IV.
 Monitor for ecchymosis when penetrating the skin with the
cannula.
 Assess for allergies to tape or dressing adhesives.
 Monitor for skin color changes, sloughing of the skin, or
discomfort at the IV site.
 Notify the HCP if tissue damage is suspected.
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IX. Central Venous Catheters
 Description
o Central venous catheters (Fig. 14-6) are used to deliver hyperosmolar
solutions, measure central venous pressure, infuse parenteral
nutrition, or infuse multiple IV solutions or medications.
o Catheter position is determined by radiography after insertion.
o The catheter may have a single, double, or triple lumen.
o The catheter may be inserted peripherally and threaded through the
basilic or cephalic vein into the superior vena cava, inserted centrally
through the internal jugular or subclavian veins, or surgically tunneled
through subcutaneous tissue.
o With multilumen catheters, more than one medication can be
administered at the same time without incompatibility problems, and
only one insertion site is present.
 Tunneled central venous catheters
o A more permanent type of catheter, such as the Hickman, Broviac, or
Groshong catheter, is used for long-term IV therapy.
o The catheter may be single lumen or multilumen.
o The catheter is inserted in the operating room, and the catheter is
threaded into the lower part of the vena cava at the entrance of the
right atrium.
o The catheter is fitted with an intermittent infusion device to allow
access as needed and to keep the system closed and intact.
o Patency is maintained by flushing with a diluted heparin solution or
normal saline solution, depending on the type of catheter, per agency
policy.
 Vascular access ports (implantable port)
o Surgically implanted under the skin, ports such as a Port-a-Cath,
Mediport, or Infusaport are used for long-term administration of
repeated IV therapy.
o For access, the port requires palpation and injection through the skin
into the self-sealing port with a noncoring needle, such as a Huber-
point needle.
o Patency is maintained by periodic flushing with a diluted heparin
solution as prescribed and as per agency policy.
 PICC line
o The catheter is used for long-term IV therapy, frequently in the home.
o The basilic vein usually is used, but the median cubital and cephalic
veins in the antecubital area also can be used.
o The catheter is threaded so that the catheter tip may terminate in the
subclavian vein or superior vena cava.
o A small amount of bleeding may occur at the time of insertion and
may continue for 24 hours, but bleeding thereafter is not expected.
o Phlebitis is a common complication.
o Insertion is below the heart level; therefore air embolism is not
common.
 Epidural Catheter
o Catheter is placed in the epidural space for the administration of
analgesics; this method of administration reduces the amount of
medication needed to control pain; therefore, the client experiences
fewer side effects.
o Assess client’s vital signs, level of consciousness, and motor and
sensory function.
o Monitor insertion site for signs of infection and be sure that the
catheter is secured to the client’s skin and that all connections are
taped to prevent disconnection.
o Check HCP’s prescription regarding solution and medication
administration.
o For continuous infusion, monitor the electronic infusion device for
proper rate of flow.
o For bolus dose administration, follow the procedure for administering
bolus doses through the catheter and follow agency procedure.
o Aspiration is done before injecting medication; if more than 1 mL of
clear fluid or blood returns, the medication is not injected and the HCP
or anesthesiologist is notified immediately (catheter may have
migrated into the subarachnoid space or a blood vessel).